This story was originally produced by the Concord Monitor. NHPR is republishing it in partnership with the Granite State News Collaborative.
As many as 29,000 people across the Granite State could lose Medicaid coverage by the time 2028 rolls around, according to a new report from the New Hampshire Fiscal Policy Institute.
As of this January, Granite Advantage — New Hampshire’s Medicaid Expansion program, which covers people up to 138% over the federal poverty limit — will require enrollees to complete 80 hours of work or community engagement activities every month.
That change is part of a slew of new requirements and narrowed eligibility enacted in the One Big Beautiful Bill Act, or H.R. 1.
With these federal work requirements coming into play, people will be required to recertify every six months. However, the state took things one step further, upping the frequency to every three months for the Granite Advantage population, which numbered around 59,000 people on average in 2025.
Edward Shanshala, Chief Executive Officer of Ammonoosuc Community Health Services, said he sees the work requirements as a potential deterrent to people on Granite Advantage.
“In those circumstances, some individuals may find it difficult to work their way through, and as such, may just give up and not seek it,” he said.
People excluded from the work requirements include caregivers, those who are pregnant or postpartum, anyone under age 19 or older than 64, those with a disability, military veterans with a “total” disability rating, inmates, and people in substance use rehabilitation, among others.
“Medicaid Expansion has been vital to reducing the state’s uninsured rate and uncompensated care costs, with New Hampshire’s uninsured rate declining by more than half following its implementation,” says the policy institute’s report, authored by senior policy analyst Jessica Williams.
In 2025, about 13% of Granite Staters were enrolled in Medicaid. About 32% of those people were covered by Granite Advantage, according to Williams. In Concord last year, more than 2,400 residents were enrolled in Granite Advantage.
Since reverting to pre-pandemic redetermination processes with regular recertifications rather than automatic reenrollment, Granite Advantage has reported an 8.3% drop in enrollment since data was collected a year ago, according to the Fiscal Policy Institute.
The state was previously using data matching tools to determine if people could keep their coverage, but because of changes made during the 2026 legislative session, it now needs to do so manually. That has contributed to some of the enrollment decline, Williams told the Monitor.
On the whole, New Hampshire has taken a more “stringent” approach to implementing federal Medicaid requirements, she said.
“Essentially, Granite Advantage adults must provide specific documentary evidence of meeting the work requirements, rather than just self-stating to meeting them, or simply just stating that they’re meeting the requirements, which is something that’s permitted for the first year of implementation under federal law,” Williams said.
The quarterly redeterminations are another example of the state’s approach to the federal rules.
Ward 3 Executive Councilor Janet Stevens, who has been advocating for health care in the Granite State, encouraged people to connect with the state Medicaid office “with their questions or concerns.”
“We don’t want people to fall through the cracks,” Stevens said.
Among the potential 29,000 folks losing coverage — with a minimum estimate of 23,000 — could be 4,000 to 6,000 young adults, Williams writes in her report, which was published on Tuesday.
As of the end of last month, almost 48,000 people were enrolled in Granite Advantage, marking a 13.5% decline compared to September one year ago, according to state Medicaid enrollment data.
These changes have already begun unfolding elsewhere.
As of August, Nebraska began disenrolling people for not meeting work requirements, and was the first state to do so, Williams said.
“What we’ve noticed is that, while most folks are complying or have an exemption, there are still coverage losses simply because it’s hard. More stringent paperwork requirements or just not being able to reach people is leading to those coverage losses,” she said.
Since Nebraska’s requirements took effect two months ago, about 7% of its Medicaid Expansion enrollees up for redetermination lost coverage, Williams found in her study. Of that portion of people, 92% “did not respond to compliance requests,” she explained.
One alternative to Medicaid for people who will be left uninsured is federally qualified health care centers, like Ammonoosuc, with a sliding fee scale, Shanshala said. At Ammonoosuc, those costs begin as low as $15 and go up to $60 for people whose income lands at less than 200% above the federal poverty limit, he said.
“In the event that someone can’t afford $15, we have processes to look at to bring it down to zero,” he said. “It does raise questions for us of: Can they afford food? Can they afford the medications? So we connect those people to patient navigators to make sure they’re getting the benefits they should get.”
However, the ability to carry out this model, he said, depends on federal taxpayer dollars.
The New Hampshire Fiscal Policy Institute warns of broader effects that will unfurl over time, with “changes to financing mechanisms” reducing funding for health services in the state.
“Reductions in provider taxes will lower the State’s Medicaid Enhancement Tax rate over time, likely forgoing more than $2 billion in State and federal funding, and threatening the stability of funding streams for the state’s Medicaid system,” the report states.
States are also expected to lose more federal funding with each enrollee who no longer qualifies.
Beyond that, experts expect to see a rise in uncompensated care, with prices that will go higher.
“When more people become uninsured, providers must either absorb the costs of uncompensated care or seek other revenue sources to maintain their operations,” the report states.
Another challenge, according to Shanshala, is that maintaining health is often easier than treating someone in an emergency for an ailment that could have been prevented through maintenance.
He uses a car analogy to explain: “You can either change the oil, or you can suffer the consequences of not changing oil, which is usually pretty expensive,” he said. “In humans, you can’t just replace the engine. Sometimes the damages are reparable, so it doesn’t make a lot of sense from a policy or budgetary perspective, state or national, to disinvest in things that have demonstrated that you want to do it right the first time.”
On a broad scale, he believes that health care — in New Hampshire and beyond — will experience market consolidation, with more and more longstanding health centers closing and none opening in their stead.
As Granite Advantage changes evolve, he remains committed to helping people weather the storm.
“It can be confusing for our patients; we try to make it less confusing, but we’re not reimbursed to do that work either,” he said. “We can’t add staff to do work that is not reimbursable. It becomes very difficult, and so we don’t have good quantification yet of what that’s going to look like.”